Provider Demographics
NPI:1952755480
Name:HOLLYSTIC HIDEAWAY
Entity Type:Organization
Organization Name:HOLLYSTIC HIDEAWAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VERNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-228-3694
Mailing Address - Street 1:1396 N 2100 W
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1418 W SUNSET BLVD. # 2
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-767-7976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable